Ultrasound: Assessment of Patients in shock

Which statement regarding the RUSH protocol is correct?

A 57-year-old patient presents with lethargy, difficulty in breathing and collapse. His initial observations are respiratory rate of 38, SpO2 of 82% on room air, heart rate of 120 and blood pressure of 80/50. He has a background of COPD and anxiety. He is wheezy on auscultation and his heart sounds normal but fast. The chest X ray is not helpful due to poor inspiratory effort. An arterial blood gas shows pH 7.35, pO2 6, pCO2 3 and lactate 4. POCUS shows:

Image courtesy of: Therese Mead, DO, Emergency Physician: thepocusatlas.com

Image courtesy of Justin Bowra: thepocusatlas.com

What diagnosis is suggested by these images and what is your management plan?

A 65-year-old patient presents with difficulty in breathing and a cough. The patient has had a dry cough for a week and a mild fever. He has had episodes of chest pain on-and-off for a month. He has a background of hypertension and dyslipidaemia.

His initial observations are respiratory rate 20, heart rate 120, blood pressure 75/40 and temperature of 37.8o C. His chest x-ray shows upper lobe diversion. POCUS shows:

Case courtesy of Dr David Carroll, Radiopaedia.org

How would you manage this patient?

A 78-year-old patient is brought into your emergency department with severe lethargy and generalised chest and abdominal pain. She has no known medical history but she drinks “a lot” of alcohol. She does not take any regular medication. Her initial observations are respiratory rate of 26, heart rate of 120, blood pressure of 70/50 and a temperature of 38.3o C. She has normal breath sounds on examination and a generally tender abdomen but no peritonitis. Her initial blood gas shows pH 7.1, pO2 12, pCO2 3,  lactate 3, Na 135, K 5.9 and Hb 135.

His cardiac views look normal to you. The additional POCUS findings are:

Image courtesy of Justin Bowra : thepocusatlas.com

Image courtesy of Josiane Almeida : thepocusatlas.com

What is the next step in managing this patient?

Which statement is correct with respect to the International Federation for Emergency Medicine (IFEM) SHOc protocol?

A 60-year-old patient presents with severe difficulty in breathing. He has a background of COPD, bullous disease and left upper lobe lobectomy. His initial observations are respiratory rate of 32, SpO2 of 82% on 15L NRB, heart rate of 140, and blood pressure of 80/50. He has reduced air entry bilaterally. His initial arterial blood gas shows pH 7.1, pO2 8, pCO2 9 and lactate of 5. You are not sure whether his chest x-ray shows a bulla or pneumothorax. POCUS shows normal cardiac views. The lung views show:

Image courtesy of Dr. Stenberg thepocusatlas.com

How would you manage this patient?

Which statement is correct regarding the assessment of the right ventricle (RV)?

A 72-year-old patient presents with difficulty in breathing. He has a background of lung cancer with liver metastases. He is lethargic and finds it very difficult to speak. He has a long-term chest drain in place on the left. His initial observations are respiratory rate of 32, heart rate of 125, blood pressure of 75/40 and temperature of 36.8o C. His chest x-ray shows cardiomegaly and a small pleural effusion on the left side. His POCUS shows:

Image courtesy of Francisco Norman thepocusatlas.com

How would you manage this patient?

Which statement regarding the IVC is correct?

Which is correct regarding POCUS assessment of the lung in shocked patients?